Current through Register Vol. 51, No. 19, September 20, 2024
A. Claims Submission. In order to be
reimbursed by the Department, an approved provider shall submit a claim when
the provider has:
(1) Obtained authorization
to provide the services for which the claim is being submitted;
(2) Delivered the service;
(3) Documented provision of service as
required; and
(4) Complied with any
regulatory preconditions for the delivery of the service.
B. Claims Retraction. The Department may
retract any payments made to any PMHS provider for paid claims if an audit
indicates that:
(1) The services were not
provided;
(2) The services were not
medically necessary;
(3) There is
no documentation that the services were provided;
(4) The precondition for the delivery of the
service was not met; or
(5) The
provider failed to comply with §H of this regulation.
C. If the Department retracts funds from a
provider under §B of this regulation, within 30 days following the
retraction the Department shall provide notice and an opportunity for a
hearing.
D. Limitations.
(1) The Department shall reimburse, for
services delivered on the same service date for the same individual, an
outpatient mental health center (OMHC) for a maximum of two therapy sessions
subject to the following conditions:
(a) Only
one may be an individual therapy session;
(b) Only one may be a group therapy session;
and
(c) Only one may be a family
therapy session, either with or without the individual.
(2) The Department may not reimburse an OMHC
for the following services delivered to the same individual on the same service
date:
(a) Individual therapy with medication
management session, and medication management session;
(b) Diagnostic interview or assessment, and a
treatment planning session; and
(c)
A diagnostic interview or assessment, and a therapy session.
(3) For all other providers, the
Department shall reimburse for only one service per service date.
(4) Limitations Exception. The Department may
provide an exception to the limitation rule on outpatient services if the ASO
finds that the service:
(a) Is medically
necessary;
(b) Is not duplicative;
and
(c) Has been
preauthorized.
E. The Department shall reimburse Psychiatric
Rehabilitation Program services provided to a child residing in a therapeutic
group home, as defined in COMAR 10.21.07 when the TGH certifies that its
negotiated rate does not include payment for the PRP services.
F. The Department may not reimburse
outpatient mental health services provided to an individual when the individual
is in a hospital or residential treatment center.
G. The Department may not reimburse PRP
providers until the PRP has met the minimum service encounters as defined in
Regulation .09 of this chapter.
H.
For individual practitioners, when services are preauthorized, the following
documentation is required before submitting for payment for services rendered:
(1) For each individual served, the medical
record, which shall include the following documentation:
(a) A signed consent to treatment;
(b) A comprehensive assessment that includes
the:
(i) Individual or family's presenting
problem;
(ii) Individual or
family's history;
(iii)
Individual's diagnosis; and
(iv)
Rationale for the diagnosis; and
(c) An individualized treatment plan that
includes the:
(i) Problems, needs, strengths,
and goals that are measurable;
(ii)
Interventions that are medically necessary; and
(iii) Signatures of the individual, or if the
individual is a minor, the guardian, and the treating mental health
professional; and
(2) Progress notes for each face-to-face
contact including:
(a) Date of
service;
(b) Start time and end
time;
(c) Location;
(d) Summary of interventions provided;
and
(e) The treating mental health
professional's signature and date of service.
I. Services rendered by an individual
practitioner may only be reimbursed for the licensed mental health
professionals authorized by the practice board to diagnose and treat
psychiatric disorders as identified in this chapter of regulations.
